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Patient Election to Self-Pay for Services
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PATIENT ELECTION TO SELF-PAY FOR SERVICES
Patient First Name
*
Patient Last Name
*
Email
*
Insurance Company
*
Self-Pay Terms
*
I agree to self-pay for services.
Certus Psychiatry and Integrated Care ("Clinic") is a participating provider with the aforementioned ("Company").
I, the undersigned patient, acknowledge that I understand and agree that:
I am covered by one of the Company Health insurance Plans.
The health plan under which I am covered includes benefits for some or all of the services provided by Clinic.
Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic.
Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receive from Clinic at their Certus Psychiatry discounted rates.
By electing to self-pay for services, any payments I make to Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with Company unless otherwise permitted under the terms of my health plan.
I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.
I have freely chosen to self-pay for services after having asked Clinic about payment options and having carefully considered those options.
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